We’ve tried to understand what patients need or why they need to stay in a hospital. And it all boils down to three factors, in our experience.

First is the fear and anxiety. Mostly the fear of the unknown or the dogma of the fact that you just stay in the hospital with this operation.

It boils down to the risk and that risk is defined by the comorbidities and medical complications that occur with the operation.

And then the side effects of what we’re doing to the patient and that mostly revolves around anesthesia and the avoidance of narcotics. The issues of blood loss, particularly with total hip replacement, and then the surgical trauma.

If you look at fear, it’s the unpleasant emotion caused by the belief that something is dangerous, likely to cause pain or a threat. So, to address fear, you must educate the patient. You educate the patient preoperatively what to expect; when they’re expecting; educate the family—“How am I going to bring Mom or Dad or husband or wife home the same day of surgery?” That’s a very easy hurdle to overcome.

The second hurdle is pre-arthroplasty rehabilitation. Again, it goes to education. Over the last two decades we’ve shown that pre-arthroplasty education reduces that fear and anxiety. It also decreases pain and improves outcomes.

Risk is defined as a situation involving the exposure to danger. What we must do here is decrease the exposure to danger.

How do we do that? We do that through what’s called preoperative medical optimization. It used to be called preoperative clearance and that’s not what we’re trying to do. What we’re trying to do is optimize the patient’s medical situation such that they can have an operation—and these are elective operations, regardless of how we look at it.

If you’re having an elective operation you ought to be well enough to have it done as an outpatient. There’s been a lot of discussion about how we identify these patients and it’s boiled down to a very, very simplistic idea. And that is do you or do you not have an organ failing? If you don’t have an organ failing, then you can have this done as an outpatient. Very simple.

If we look at the side effects, we’re looking at the undesirable effect of a drug or medical treatment. Basically, what we’re talking about is going through a laundry list…a very well-articulated laundry list of how to avoid or reduce the amount narcotics the patient takes preoperatively, intraoperatively, and postoperatively.

MIS does not mean minimally invasive surgery. It doesn’t matter. The surgical approach doesn’t matter. The operation itself doesn’t matter. It’s the skillfulness in avoiding wasted time that defines what is called minimally invasive and it’s basically the efficiency of the operation.

It’s important to understand why this is occurring and the multiple stakeholders that are involved. It involves the cost, control, the surgeon, the patient, and the health system. All these come together—and there’s no other way to define it—when all these things come together it equals outpatient arthroplasty.

There have been multiple studies which show significant cost savings and significantly better reimbursement in terms of cost-to-reimbursement ratio by doing these procedures as an outpatient.

A recent study showed almost a $7,000 cost savings per procedure for the system—which can be enjoyed by all stakeholders.

In our series, we looked at 3,200 arthroplasty procedures over the last three years. Only 7% had to stay overnight. Half were for convenience. Nine out of 3,000—stayed because of pain. We had 98% patient satisfaction.

We’ve got 1,252 total hips to look at. Overnight stay 6%, just under half for medical tourism or convenience. Just over half for urinary retention, obstructive sleep apnea or postoperative nausea and vomiting.

Non-operative complications were less than 1% and those patients either went to an ER or were admitted to a hospital, died, or had a significant postoperative complication. That’s less than 1%. That has nothing to do with the operation and the timeframe of these complications has nothing to do with them going home the same day.

But…it does have to do with medical optimization preoperatively. These are healthy patients that can go home. They don’t need to be subjected to unnecessary hospitalization.

Operative complications were less than 2%. All together we had less than 3% of either readmission, operative complication or medical complication and that’s significantly lower than that reported in the literature for almost any hospitalization. Patient satisfaction is high at almost 98%, meaning patients don’t feel like they’re being pushed out or they’re going home without the education, without the proper training.

I’ve just shown you a 2.2% 90-day readmission or complication rate, which is about a quarter of that in the literature. And 98% good to excellent satisfaction. The paradigm shift has already occurred, and the future is now.

Dr. Lieberman: Total hip replacement…let’s define it. We’re talking about total hip replacement performed in an ambulatory surgery center or hospital where the patient is discharged the same day as the procedure. I routinely discharge patients on postoperative day 1. Not really against it. Larry Dorr does this at our institution. He’s done it successfully. But I think there are some caveats.

It needs to be demonstrated that it’s better for the patient. There are no appropriately powered multi-centered randomized trials demonstrating the advantage with same day surgery. Why would the patient want to go home?

Why should the patient go home? Is it safer for the patient? Is it better to drive home the same day and sit in a car for an hour or two? Is it better to be home if you’re nauseous? Will the patient be more comfortable at home? Is it easier on the spouse to have to take care of the patient? The patients go home because they’re told they should go home.

The safety needs to be confirmed. What are the selection criteria? What are the risk factors for admission to the hospital? What are the risk factors for readmission once the patient goes home?

A study from John Callaghan’s group looked at early discharge and complications using the AJRR database. It gets data from 674 hospitals in a prospective fashion. They looked at demographics, comorbidities, 30-day complications and readmissions. They propensity-matched comparisons between postoperative day zero and postoperative day one discharge and then they did a statistical analysis. There were no differences in complications or readmissions after total knee or unicondylar knee, but in total hip replacement patients there is increased rate of complications in same day surgery.

The risk factors for that were age greater than 70; smoking, COPD; coronary artery disease; and hematocrit less than 36.

Total hip replacement discharge on postoperative day zero significantly riskier than day one. They also had higher rates of diabetes; steroid use; and lower hematocrit and serum albumin.

The total knee group had higher percentage of ASA 3 and 4.

Patients discharged on postoperative day zero had higher unadjusted rates of 30-day complications to total hip/knee and unis.

So even though we say that we have good selection criteria, obviously from looking at the AJRR database study, it’s not followed. And they concluded that a hospital admission is probably the best plan for a patient not optimized for outpatient joint arthroplasty and I think Keith would agree.

Careful screening is needed, but in real-life practice this needs to be improved.

Goyal et al., published a randomized trial at two centers looking at outpatient versus inpatient surgery.

They looked at postoperative pain, perioperative complications, as well as the surgeon’s staff work effort. Inclusion criteria: age less than less than 75, BMI [body mass index] less than 40; no chronic opioids. Patients received the primary total hip via an anterior approach. They found no difference in pain on the day of surgery between the two groups. But on postoperative day one, there was a significantly higher increase in pain for the postoperative day zero group.

So, one day after surgery, higher pain in the patients who were discharged on the same day. No difference in complications. No difference in work for the surgeon’s office, but they lacked sufficient power to really analyze this. And 24% of the patients were unable to be discharged.

There are difficulties with same day discharge, which has been pointed out in the literature—nausea and hypotension are problems. Dorr’s study noted that only 36% of patients wanted to leave on the day of discharge. And only 77% could be discharged. In Berger’s study everyone was able to be discharged but 25% required additional treatment that delayed discharge and it was usually nausea and hypotension.

Social factors can clearly influence the process. How far is the patient living from the hospital? How long is that drive going to be? Do they have the appropriate support at home if they go home the same day?

I think there are some other issues that need to be resolved. What kind of system do you have in place to make sure the patient selection is done in a meticulous fashion?

Another issue is if the doctor owns the outpatient surgery center, is it a conflict of interest to push patients to have a same day discharge? Should the surgeon tell the patient that he or she has a financial incentive to have a same day discharge?

I think that same day total hip replacement may be done in a safe, effective manner. We need to clearly define the indications and contraindications for same day discharge. One needs to develop a screening system and well-defined protocols in your institution related to pain management, anesthesia, and physical therapy. As seen in the literature, this is not being followed now.

What happens to patients that cannot be discharged? Where are they going to go? So, if you’re in an ambulatory surgery center, you need to have some observation capability or an arrangement with a hospital. And remember we need to do what is best for each individual patient or we’ll lose the trust of the public.

Moderator Thornhill: So Keith, Jay’s asked you a whole bunch of questions. Did you write any of them down?

Dr. Berend: I did. We must disclose to the patient that we own the surgery center and that we have a financial influence and will benefit performing their procedure at the surgery center. That’s every single patient that walks in whether they go to the hospital or not or whether they go the surgery center.

That’s the law. You can’t NOT do that.

Probably the overriding biggest question was why would you NOT want to go to the hospital, which to me clearly is to avoid unnecessary tests and procedures.

At my hospital they require a Foley catheter for any male that has had a history for anything that has to do with his prostate, urine, kidney, bladder, etc. So, the patient has to have an unnecessary Foley. Unnecessary lab work. To have a machine that beeps. To have the nurse to wake you up to make sure you’re asleep. You have to hit the call button to go to the toilet. Patients don’t want that. We don’t subject patients with any other operation that’s considered an outpatient—your ACL, your gall bladder, your thyroid…we just don’t do that anymore. And that’s where total hip replacement is in 2017.

Moderator Thornhill: I asked one of the speakers here at another meeting…he’s a great educator, great teacher, great everything and good institution…and I asked him the question about education and he basically talked about the lack of support he got from his hospital. Sort of what Keith was saying…You get wakened up to see if you’re asleep and all the stuff. Is this a problem? What can you do as chairman of the department to make everything work perfectly for you and the patients at your institution?

Dr. Lieberman: Some of those are JCAHO laws that they must have. We checked into this because most of my joints go home the first day. So, we wanted to eliminate some of these blood pressure checks, but they’re JCAHO rules so maybe they should look at that. I think that is an issue. But I’m not sure that everybody wants to take their patient home. I’ve had a lot of patients say after the first night that they’re ready to go. I think that it’s fine if you’re going to do it, but you just need to set up a system as Keith has.

There’s one thing that Keith said that I think is the slippery slope here. He said if you don’t have any organs failing it’s okay to do it. I think we must be careful about that kind of stuff because the first thing you know it’ll be “Well, you only have one organ failing.” Or “it’s only two organs failing.” Or, “the organ is close to failing, but we’re going to be doing it.” I think need to watch that or we’re going to have trouble with some of these patients.

Moderator Thornhill: I’d just soon get off the subject of failing organs, so let me just go back. When you moved to the outpatient, were you pushed or were your pulled?

Dr. Berend: I was doing the pushing and doing most of the pulling. As I showed, the multiple stakeholders in this situation, and as Jay mentioned, with full disclosure there’s a significant benefit to me personally and there’s a significant benefit to the system to do this as an outpatient, so I was doing all the pushing and most of the pulling.

Senior Editor: Jay D. Mabrey, M.D., whose 35 year career in orthopedics included residency at Duke University Medical Center, service in the United States Army Medical Corps, Fellowship at the Hospital for Special Surgery and a long, distinguished career at Baylor University Medical Center where, in addition to his overall leadership at that institution, developed the Joint Wellness Program that helped patients get up after surgery more quickly, developed the first virtual reality surgical simulator for knee arthroscopy and chaired the FDA Orthopaedic Device Panel, is Orthopedics This Week’s contributing writer and editor.

Dr. Berend: These are exciting times for us in arthroplasty. We talk a lot about implants and implant science and I think this will be a little bit more on procedure, protocol, and surgeon mental health, which is an ever important topic.

The four things to consider when you’re thinking about outpatient joint replacement are: the right patient, the right operation, the right surgical facility and the right surgical team. So it’s a multi-faceted decision to go down this pathway.

We’ve learned a lot about implants, fixation, various titanium, bone grafting, but I think that some of the anesthetic protocols have really led to same-day arthroplasty. This has happened for ACL reconstruction. It’s happened for many shoulder operations, upper and lower extremity sports medicine, foot and ankle, and even spine surgery now. So I think arthroplasty is following suit and for the right selected patients we’ve had great success in this space.

You may ask yourself, “Why do patients stay in the hospital.” I think there are three main reasons. The first is the fear or anxiety that goes along with having a major arthroplasty procedure; the fear of the unknown. The second is the risk or the co-morbidities associated with treatment; or medical complications that may follow. And then the third, and something we’ve really thought a lot about, is the side effects of our treatment. And these include narcotics; various anesthetic techniques where we don’t have a role in controlling anesthesia; blood loss with the admin of tranexamic acid; and some other techniques. These have been markedly reduced. And then some of the smaller incision operations lend themselves to this space as well.

Barrack, Berend Debate Surface Replacement Arthroplasty

Elizabeth Hofheinz, M.P.H., M.Ed. • Mon, June 17th, 2013

Robert Barrack says, “Our work has found significant differences favoring surface replacement.” But, in Keith Berend’s view: “This is not a viable option for most patients or surgeons."

This week’s Orthopaedic Crossfire® debate is “Surface Replacement Arthroplasty: Still a Viable Option.” For the proposition is Robert L. Barrack, M.D. from Washington University School of Medicine in St. Louis, Missouri; against the proposition is Keith R. Berend, M.D. from Mt. Carmel New Albany Surgical Hospital in Ohio. Moderating is Thomas Thornhill, M.D. from Harvard Medical School.

Dr. Barrack: “Given the high rate of success of total hip arthroplasty (THA), high risk alternatives are not warranted. So surface replacement (SRA) must demonstrate a similar complication rate, there must be some clinical advantage, and there must be a reasonable learning curve to warrant continued use of this procedure.”

“There are major short term complications with THA that lead to morbidity, dissatisfaction, and lawsuits. Where can we improve? Dislocation and limb lengthening are big problems; dislocation rates are generally accepted as being lower in SRA, but the lower incidence of perceived limb length discrepancy is among the potential advantages.”

“Other potential advantages have been suggested and include a higher level of function/activity, less thigh pain, and less stress shielding. The problems with prior studies are that they’ve been low in numbers, been underpowered, and had a lot of potential for observer bias because of the absence of independent, blinded parties.”

“We need to document: clinical advantage, a reasonable learning curve in the hands of a number of surgeons, and less stress shielding. Also, the clinical results…not just at specialty centers, but in large data sets.”

“We did a national multicenter study to see if there was a discernible clinical difference among current THA implants with advanced bearings compared to surface replacements in young, active patients. We overcame observer bias by using an unbiased, blinded survey center that has expertise in administering questionnaires for federal and state agencies.”

“There were over 800 patients; we found significant differences that favor surface replacement. There is a substantial difference in those that perceived a limb length discrepancy; thigh pain is perceived much more frequently by total hip patients than by SRA patients.

Dr. Berend: I’d like to share with you our experience with a new type of pharmacologic technology and I think it has made a big difference in our practice.

The definition of a game changer is an event or an idea or a procedure that effects a significant shift in the current manner of doing or thinking about something. Liposomal bupivacaine is part of a series of events that’s really changed our practice from inpatient surgery to better pain control and outpatient surgery.

Liposomal bupivacaine was a game changer for us. It’s basically Marcaine held in a fatty membrane. Those fatty membranes are grouped together, injected into the pericapsular tissues and then with body heat and pH, the membranes erode and release the medication—sort of a time release capsule for local anesthesia.

We’ve experienced a lot of other game changing things in arthroplasty: the comprehensive joint replacement project, or bundled payment care, which will certainly pressure us into reducing costs and other system changes. This has forced us to reexamine the entire care pathway for joint replacement and I think liposomal bupivacaine plays a role in that algorithm.

Our current protocol focuses on preemptive pain control with preoperative medications of Celebrex and Neurontin and acetaminophen. We’ve eliminated narcotic spinals in favor of short-acting local anesthesia spinals. We use an adductor canal block administered under ultrasound which conserves the quadriceps function. We use a general anesthesia with a laryngeal mask for rapid induction. Tranexamic acid has now eliminated the need for post-operative laboratory monitoring. We use a pericapsular injectable cocktail—some with liposomal bupivacaine at the hospital some with a different recipe at our ASC [ambulatory surgery center], and a whole host of medications aimed at pain control and nausea control.

Jones v. Berend: The Tourniquetless TKA: Let It Bleed

OTW Staff • Thu, November 3rd, 2016

This week’s Orthopaedic Crossfire® debate was part of the 32nd Annual Current Concepts in Joint Replacement® (CCJR), Winter meeting, which took place in Orlando this past December. This week’s topic is “The Tourniquetless TKA: Let It Bleed.” For the proposition is Richard E. Jones, M.D., University of Texas, Southwestern, Dallas, Texas. Opposing is Keith R. Berend, M.D., Mt. Carmel New Albany Surgical Hospital, New Albany, Ohio. Moderating is Kelly G. Vince, M.D., F.R.C.S.(C), Whangarei Hospital, Whangarei, New Zealand.

Dr. Jones: Let it bleed. What are the benefits of using a tourniquet? Well, you operate in a bloodless field and potentially you have a better bone cement implant interface for fixation. I say potentially because that’s now been proven not to be true.

Potential problems with tourniquet. Just think about it, augggghhh. Delay in recovery of muscle function. Slower functional recovery. Altered hemodynamics when you exsanguinate the limb because you get a 15-20% increase in circulatory volume. A reactive hyperemia when you release the tourniquet and a 10% increase in size of the limb. Vascular injury is certainly high risk in those patients with calcified atherosclerotic vessels.

More vascular risk of DVT [deep vein thrombosis] with direct trauma to vessel walls; increased levels of thrombin/anti-thrombin complexes and a 5.3 times the risk increase with large venous emboli propagation looked at with transesophageal echocardiography. Potential problems with increase in wound healing disturbances, higher propensity for wound leakage, and, shown to show, slower functional recovery.

For the last 15 years, we’ve gone with no tourniquet on any TKA, primary or revision. Our operative protocol is regional anesthesia to control blood pressure and reduce bleeding; we make our incision with the knee flexed to 90 degrees; it’s amazing how little bleeding occurs; and you can meticulously obtain hemostasis because you see all the vessels. They’re readily coagulated and we use an argon beam coagulator.

Our operative protocol is 0.25% ropavicaine with epinephrine injected periarticular, coagulate all those posterior vessels when you’re doing your flexion tension balancing and can look at it, then saline jet lavage with antibiotics.

We use filtered carbon dioxide delivered under pressure with a CarboJet to dry and prepare the bone beds, very much like the dentist will blow your tooth out before he cements a crown.

Berend v. Sculco: Four Rounds Over Anterior Approach

Elizabeth Hofheinz, M.P.H., M.Ed. • Thu, April 3rd, 2014

“The anterior approach has a faster recovery and optimizes outcomes when compared with a direct lateral approach, ” says Keith Berend. Hold on, says Tom Sculco. “The posterolateral approach is a common approach that can easily be extended, involves less blood loss, and is expeditious.”

This week’s Orthopaedic Crossfire® debate is “The Mini-Anterior Approach: Optimizes THA Outcomes.” For the proposition is Keith R. Berend, M.D. from Mount Carmel Health System and Joint Implant Surgeons in Ohio; against the proposition is Thomas P. Sculco, M.D. from the Hospital for Special Surgery in New York. Moderating is Robert T. Trousdale, M.D. from Mayo Clinic.

Dr. Berend: “There are results in the literature over the past decade that taught the benefits of the direct anterior approach. Such as: it’s safe and reproducible, there may be less blood loss, less pain, shorter hospital stays, fewer readmissions, perhaps better implant positioning because of visualization or fluoroscopy, less muscle damage, and overall better recovery compared with other approaches.”

“The problem is that there are an equal number of studies that are very well designed and performed and that show that it can be dangerous and difficult to teach…that show a chance of more blood loss, there’s no benefit over more common approaches, there are more outliers in terms of implant positioning because of decreased visualization, perhaps more or different muscle damage, and that there’s no significant difference between recovery with an anterior approach versus some of the other approaches.”

“My JBJS study from 2009 compared the less invasive direct lateral approach with my early experience with the anterior supine intermuscular (ASI) approach. We found that early on there was a slight trend toward picking lighter patients for this approach—although I don’t do that any longer. The OR time was very similar in both of these approaches, but there was more blood loss intraoperatively with the ASI. And there was nearly double the transfusion rate with that approach (although it wasn’t statistically significant).”

“We did see a slightly shorter length of stay, a significantly better discharge deposition (meaning that patients were more likely to go straight home and less likely to need rehab).